DM Hx

Diabetes mellitus [select value="Type 2|Type 1"], diagnosed in [text default="yyyy"]In reviewing the history, the patient is followed [select value="by a primary care physician|by the diabetes clinic|by primary care physician and diabetes clinic|by the family medicine team|other" name="provider"][conditional field="provider" condition="(provider).is('other')"] [text size=30 default="other provider"][/conditional].In the past year the patient has had the following diabetic visits: [select value="no|one|two|three|four|five|more than five"] visits in the hospital, [select value="no|one|two|three|four|five|more than five"] visits to the ER, and [select value="no|one|two|three|four|five|more than five"] outpatient visits.The patient [select value="is following an optimal diet|is having difficulties following the diet|is not following a diet|would like further education on their diet"]. The patient has [select value="no|some" name="diet_concerns"] specific concerns about diet. [conditional field="diet_concerns" condition="(diet_concerns).is('some')"] [textarea default="specific diet concern details..."][/conditional].The patient routinely exercises [select value="never|once a week|2 times a week|3 times a week|4 times a week|5 times a week|6 times a week|7 times a week"]. The type of exercise is [text size=50]. Overall, the patient is exercising [select value="approximately|more than|less than"] 150 minutes per week.The patient has a history of the following diabetes complications:
[select value="NO|YES" name="DKA"] <--
Diabetic ketoacidosis [conditional field=DKA condition="(DKA).is('YES')"] [text default="diabetic ketoacidosis details" size=140][/conditional]
[select value=NO|YES name="HHS"] <-- Hyperosmolar hyperglycemic state [conditional field=HHS condition="(HHS).is('YES')"] [text default="hyperosmolar hyperglycemic state details" size=140][/conditional]
[select value=NO|YES name="hypoglycemia"] <-- Hypoglycemic episodes [conditional field=hypoglycemia condition="(hypoglycemia).is('YES')"] [text default="hypoglycemic episode details" size=140][/conditional]
[select value=NO|YES name="eye"] <-- Eye complications [conditional field=eye condition="(eye).is('YES')"] [text default="eye complication details" size=140][/conditional]
[select value=NO|YES name="kidney"] <-- Nephropathy [conditional field=kidney condition="(kidney).is('YES')"] [text default="nephropathy details" size=140][/conditional]
[select value=NO|YES name="neuro"] <-- Neuropathy [conditional field=neuro condition="(neuro).is('YES')"] [text default="neuropathy details" size=140][/conditional]
[select value=NO|YES|N/A name="OB"] <-- Obstetric complications [conditional field=OB condition="(OB).is('YES')"] [text default="obstetric complication details" size=140][/conditional]The following prevention program has been set up and includes:
[checkbox value="one time Pneumovax|yearly vaccination with Influenza|foot care instruction|preconception counseling"]MONITORING:
The patient performs monitoring of blood glucose [select value="once a day|twice a day|three times a day|four times a day|once a week|twice a week|three times a week|at no specific times|at clinic visits"].
The patient's goals for diabetes control are:
[checkbox value="MORNING (FASTING) BLOOD SUGAR LESS THAN 130. "]
[checkbox value="BLOOD SUGAR PRIOR TO MEALS OF 80-120. "]
[checkbox value="BEDTIME BLOOD SUGAR LESS THAN 120. "]
[checkbox value="HEMOGLOBIN A1C LESS THAN 7 WITHOUT SIGNIFICANT SYMPTOMS. "]
[checkbox value="HEMOGLOBIN A1C LESS THAN 8. "]
[checkbox name=control value="Other: "] [conditional field=control condition="(control).is('Other: ')"] [text default="diabetes control details" size=140][/conditional].INSULIN
The patient [select name=insulin value="does not use insulin|uses long-acting insulin only|uses short-acting insulin only|uses long- and short-acting insulins"].
[conditional field=insulin condition="(insulin).is('uses long-acting insulin only')||(insulin).is('uses short-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient does not adjust insulin. "][/conditional]
[conditional field=insulin condition="(insulin).is('uses short-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient adjusts short-acting insulin based on glucose checks before meals. "][/conditional]
[conditional field=insulin condition="(insulin).is('uses short-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient adjusts short-acting insulin based on carbohydrate counting. "][/conditional]
[conditional field=insulin condition="(insulin).is('uses long-acting insulin only')||(insulin).is('uses long- and short-acting insulins')"][checkbox value="The patient adjusts long-acting insulin based on fasting glucose trend. "] [link url=//soapnote.org/endocrine-metabolic/long-acting-insulin-self-3-3/ memo="3 by 3 long-acting insulin adjustment instruction for patients"][/conditional]